In-depth interviews with SS trainees and friends
Of 20 people approached, 19 in-depth interviews were completed with Stepping Stones (SS) participants (10 males and 9 females), all from different villages. The other audio tape was inaudible and was discarded. At the time of training in 2005, half these participants were married and half unmarried, but at the time of the interviews in November 2007, 7/10 men were married as were 5/9 women. The mean age of the male respondents was 24 and of the women was 28.4 years.
Twenty friends (SSF) were also interviewed but again one audio tape was inaudible and was discarded, so we completed 19 interviews (SSF) (10 males and 9 females) with people from different villages. All were friends of the SS participants, though one was also a cousin. Nobody brought along close relatives or anyone of the opposite sex. Of the 10 SSF males, 3 were married; of the 9 SSF women, 6 were married. The mean age of the SSF male respondents was 23.5 and of the SSF women was 26.4 years.
Most SS and SSF respondents had completed high levels of formal education. Despite this, most were engaged in manual jobs or were unemployed. Of the SS participants, four of the men classified themselves as farmers, one as a student and the others had manual jobs such as carpenter, shop assistant, cable operator. Four of the SS women classified themselves as farmers, 3 as unemployed, one as a tailor and one as an anganawadi (village health worker). Of the SSF male respondents, most were in manual occupations, though one was a teacher, one a student and one a driver. Of the SSF women, 4 identified as farmers, 3 as unemployed, one as a tailor and one as a cook.
All 19 participants, irrespective of how they were selected, reported being very happy with the training: they commented that it was extremely relevant to their lives, had opened their eyes to key issues, made them think about their relationships and had helped them to change. Most comments reflected that SS training had helped growth and maturity, preparing them for a happy family life. One young man commented "SS is not just useful-it shapes our lives. Just as we can purify dirty water, so has SS made my life clear and sparkling."
One young woman's comments epitomized the general consensus about the training:
"I feel my capacity has been built to deal with any situation and face any problem in life. I am getting married and I feel this training will be with me forever. I am prepared for entering married life and a sexual relationship with an emphasis on safety. I am confident that I can speak to my husband about my feelings and about sex, what I like and dislike, and about protection through condom use. I knew nothing about the joys and sorrows of sex before."
Surprisingly respondents could recall much of what had been taught 2-3 years earlier and often could remember the names of the specific sessions. Most said that they particularly enjoyed those sessions that focused on loving relationships. Although discussions about sex are rather taboo in Indian society, especially for unmarried boys and girls, every respondent affirmed that sex should be a key area of discussion in SS training. Seven participants said that at first they felt uncomfortable or embarrassed, but all agreed that they had learnt a lot, and that it was very important for their health and life: "life can get very badly affected because of secrecy and shyness. Discussions about these things lead people to seek treatment, support HIV prevention efforts and leads to better health for all". Married women felt that the discussions of sex gave them the information they needed to confront spouses: "I told my husband about sexual relationships and the HIV infection that spreads through sex. A wife has to talk to her husband to protect herself...I took condoms from the clinic and he used them."
All respondents, irrespective of how they were selected, were vocal when asked about gender relations in the community. Many mentioned that there was a problem in a society that treated women as inferior, where girls were not encouraged to go to school or have careers, where men and women were prevented from talking openly together, where early marriage and marriage of nieces or first cousins was the norm, and most importantly, when men perpetrated violence against women. The males themselves mentioned that they used to think that girls who talked to boys were "loose" or available for sex, but that SS had changed their ideas. The SS respondents reported that the training had made them personally reflect on what needed to be done to improve equality. Many reported that gender relations in their villages had improved after the SS training, starting by them modelling behaviours in their own home and with their peers.
All respondents also reported gaining new information on HIV and other STIs, how to manage healthy relationships and once they understood about HIV, the need to reduce stigma against people with HIV/AIDS (PLHIV). The men mostly reported changes in personal behaviours, especially reduction in alcohol use, reduction in multi-partner sex, increase in condom use and increased respectfulness towards women. The women mostly reported an increase in courage and confidence to face issues. Their testimonies reveal a strong sense of pride: "I have increased self-confidence...in my family, my parents are happy that their daughter is a complete young woman, that even in marriage she knows how to have a fulfilled life. Now I tell my parents what my dreams are, how I have confidence to face problems when they crop up".
All respondents, irrespective of how they were selected, commented that they had shared their new ideas with friends and relatives, despite not being formally encouraged to do this during the training. They also mentioned that there was little support from the facilitators to stay together as a group and take on concrete community activities after training. Despite this, they noted such changes in the community as: more discussions, more knowledge about sex and HIV, and less fear of HIV, more self-help groups who were generally improving the village; more respect for women, improved gender relations, more girls in school; more testing and treatment for diseases like STIs; a reduction in smoking, drinking, risky sex and violence against women; an improvement in attitudes to devadasi (traditional caste-based sex workers); general increased levels of responsibility and use of condoms.
SS trainees' associates were interviewed to triangulate some of the responses given by the SS respondents. All 19 respondents remembered that their friends went for this training and all remembered being told about it. Most males specifically mentioned that their friend had told them about HIV/AIDS, how to use condoms and how to reduce risk. They had also learnt from them about caring for positive people (PLHIV) and about being tested themselves. The respondents noted also that their SS friend had discussed with them appropriate behaviour with, and respect for, girls. Among the female associates, information sharing appeared to be slightly different, with recollections much broader than just reduction of risk behaviours and HIV. They were more likely to mention issues such as how to communicate with people, how to develop healthy family relationships, trust and confidentiality, how to care for PLHIV, how to be self-confident and take on issues of importance, how to challenge unhealthy traditions, how to convince men to behave more responsibly in the areas of drinking and womanizing and how to love and keep your man at home.
Polling booth results
Table
1 shows the profiles of the 2,887 people who participated in the PBS. The profiles of the general populations were very similar. However, there were a greater number of older married women, younger married and unmarried males among the SS trainees than in the general population samples. Adjusted data for the SS group are presented.
All participants answered every question by putting a token in one of three boxes, and we present the "yes' answers (agree answers in the case of the attitude questions). Two people in the SS sample left before answering the attitude section of the PBS. Tables
2,
3 and
4 show the different responses in the three study populations. Where the differences were statistically significant from the population in the previous column (for example, comparing SS trainees with people in their villages, or comparing people in SS villages with people in non-SS villages), asterisks show statistical significance; (
p< 0.05, one asterisk) or (
p< 0.01, two asterisks).
Table 2
HIV knowledge (% respondents responding "yes" to the statement)
Have you have heard of HIV? | 92.8 | 75.0 (0.00)** | 72.5 (0.16) |
Have you ever received any information about HIV? | 79.7 | 57.9 (0.00)** | 56.1 (0.36) |
Can HIV be transmitted by mosquito? | 29.8 | 28.8 (0.70) | 44.3 (0.00)** |
Can HIV be transmitted by sex? | 76.1 | 58.0 (0.00)** | 53.6 (0.27)* |
Can you tell by looking who has HIV? | 26.8 | 23.4 (0.16) | 37.6 (0.00)** |
Do you think condoms protect against HIV? | 72.4 | 53.8 (0.00)** | 69.5 (0.00)** |
Do you think anal sex is safe and a way to avoid HIV? | 25.4 | 21.5 (0.10) | 34.6 (0.00)** |
Do you know where to get condoms? | 76.4 | 59.4 (0.00)** | 56.9 (0.21) |
Have you ever seen a demonstration on how to put on a condom? | 61.2 | 39.7 (0.00)** | 34.1 (0.00)** |
Table 3
Attitudes (% respondents agreeing with the statement)
Attitudes to HIV and PLHIV |
I would care for a PLHIV relative at home | 77.2 | 64.9 (0.00)** | 60.2 (0.02)* |
I would not buy vegetables from a person with HIV | 39.6 | 47.5 (0.00)** | 46.5 (0.62) |
HIV child should not be allowed in school | 30.1 | 40.4 (0.00)** | 40.9 (0.80) |
If a woman has HIV, it is a reflection of moral character | 44.6 | 46.8 (0.44) | 46.4 (0.84) |
Families with HIV should be left alone | 33.7 | 37.8 (0.14) | 40.9 (0.11) |
Gender and sexuality
|
It's OK for women to suggest condom use | 72.8 | 58.0 (0.00)** | 54.8 (0.11) |
Girls with too much education are not good wives | 31.2 | 39.5 (0.00)** | 44.3 (0.02)* |
Girls should be married as soon as possible | 45.8 | 52.5 (0.02)* | 51.6 (0.65) |
Women should feel free to show husbands if they want sex | 59.7 | 53.6 (0.03)* | 51.4 (0.27) |
Women should be blamed for spreading AIDS | 29.3 | 32.3 (0.26) | 38.7 (0.00)** |
Men who cook are not real men | 76.5 | 72.6 (0.12) | 72.0 (0.74) |
Caring and sharing
|
You don't talk about sex, you just do it | 42.7 | 50.7 (0.00)** | 46.4 (0.03)* |
It's a woman's responsibility to avoid pregnancy | 38.2 | 45.7 (0.00)** | 43.5 (0.27) |
Man should have the final word about decisions in the home | 52.9 | 64.0 (0.00)** | 63.4 (0.76) |
An ideal husband controls his wife | 71.9 | 75.6 (0.14) | 72.5 (0.08) |
Women should give their earnings to the husband | 58.4 | 64.9 (0.02)* | 67.2 (0.23) |
Gender based violence
|
Men cannot control their sexual urges | 49.4 | 44.8 (0.11) | 51.2 (0.00)** |
It's OK for a man to force his wife to have sex | 39.8 | 42.0 (0.43) | 50.3 (0.00)** |
There are times when a woman should be beaten | 53.8 | 57.4 (0.20) | 60.4 (0.13) |
Raped women are usually at fault | 31.6 | 30.4 (0.65) | 34. 1 (0.05) |
Table 4
Behaviours (% respondents responding "yes" to the statement)
Openness to new ideas |
Have you discussed sex with spouse in last 6 months | 46.1 | 32.9 (0.00)** | 35.6 (0.16) |
Do you discuss finances with your spouse? | 60.1 | 45.0 (0.00)** | 44.1 (0.65) |
Have you been to a meeting about HIV in last 6 months? | 61.1 | 40.6 (0.00)** | 40.7 (0.96) |
Do you know any people with HIV/AIDS? | 51.0 | 35.7 (0.00)** | 36.0 (0.88) |
Of those who know a PLHIV, have you ever helped a PLHIV? | 60.8 | 58.1 (0.34) | 45.0 (0.00)** |
Would you be willing to be tested for HIV? | 57.4 | 46.7 (0.00)** | 44.1 (0.19) |
Have you been tested for HIV? | 24.0 | 16.9 (0.00)** | 16.4 (0.74) |
Alcohol and forced sex
|
Do you use alcohol? (Men only) | 38.3 | 42.8 (0.11) | 48.9 (0.00)** |
Does your husband consume alcohol (Married women only)? | 28.6 | 30.7 (0.42) | 36.5 (0.00)** |
Have you forced any woman to have sex in last 6 months? (Men only) | 9.0 | 5.0 (0.00)** | 7.2 (0.02)* |
Risky behaviours
|
Have you had more than 1 partner in last 6 months? | 8.1 | 9.8 (0.31) | 14.9 (0.00)** |
Was a condom used every time had ex-marital sex? (Married people only) | 66.6 | 34.3 (0.00)** | 45.7 (0.00)** |
If more than 1 partner, was a condom used every time? (Unmarried people only) | 83.6 | 51.7 (0.00)** | 55.4 (0.06) |
Have you been to a sex worker in the last 6 months? (Men only) | 4.9 | 6.0 (0.41) | 10.8 (0.00)** |
On the last time you had sex with a sex worker, was a condom used? (Men only) | 59.1 | 43.2 (0.00)** | 48.7 (0.00)** |
Did you have anal sex with a man in last 6 months? (Men only) | 5.8 | 2.2 (0.00)** | 3.1 (0.16) |
Did you use a condom the last time you had anal sex with a man? (Men only) | 44.0 | 29.0 (0.00)** | 35.4 (0.00)** |
Knowledge of HIV and transmission modes
Overall, the SS trainees had more knowledge than the general population and in turn the SS villages' general population was more knowledgeable than people in the non-SS villages (Table
2). The SS trainees were more likely to have heard of HIV/AIDS than the general population (92.8% vs.75%,
p < 0.01), more likely to have had specific information (79.7% vs. 57.9%,
p < 0.01), and more likely to know that HIV can be transmitted sexually (76.1% vs. 58.0%,
p < 0.01). SS trainees were much more likely to know that condoms can protect against HIV than the general population (72.4% vs. 53.8%,
p < 0.01), to know where to get a condom (76.4% vs. 59.4%,
p < 0.01) and more likely to have seen a condom demonstration (61.2% vs.39.7%,
p < 0.01). On many of these indicators, the people living in SS villages were much more knowledgeable than people in non-SS villages.
Attitudes to PLHIV
Five questions were asked to all respondents about their attitudes to people living with HIV/AIDS (Table
3). On three of the indicators, whether they would care for a PLHIV in the home (77.2% vs. 64.9%,
p < 0.01), whether they would buy vegetables from a PLHIV (60.4% vs.52.5%,
p < 0.01) and whether a child with HIV should be allowed in school (69.9% vs. 59.6%,
p < 0.01), the SS trainees scored higher than the general population in their villages and differences were all were statistically significant.
Very little difference was seen between the general populations of the two types of villages: only the different answers to the question about caring for a PLHIV were statistically significant (64.9% vs. 60.2%, p = 0.02). Overall, more than one third of the respondents had negative attitudes to PLHIV. Almost half the respondents in all groups, including those who had been trained in SS, thought that being HIV positive was a reflection of moral character.
Gender and sexuality
On indicators related to female roles, the SS trainees again showed more gender equitable attitudes than the general population (Table
3). The general population respondents were more likely than SS respondents to agree with the statement that girls with too much education do not make good wives (39.5% vs. 31.2% respectively,
p < 0.01), more likely to agree that women should be blamed for spreading HIV (32.3% vs. 29.3%, not significant (ns), and less likely to think that it is OK for women to suggest condom use with their husbands (58.0% vs.72.8%,
p < 0.01). However, even among the SS trainees, many had deeply ingrained socially-sanctioned attitudes to marriage, to whether women are responsible for HIV, and about whether women should make sexual advances to their spouses.
The general population of SS villages had slightly more progressive views than the general population in non-SS villages in some areas, for example 39.5% of those in SS villages believed that girls with too much education do not make good wives, compared to 44.3% of those in non-SS villages (p = 0.02) and fewer believed that women should be blamed for spreading HIV (32.3% vs. 38.7%, p < 0.01). In other areas, there seemed to be little difference in attitudes between those villages with an SS intervention and those without. The idea of men cooking appeared to be an anathema in all groups.
Attitudes to sharing, caring and responsibility
After training, we expected that SS trainees and people in their villages would show more gender-progressive attitudes, with respect to sharing responsibility and decision-making in the home. In general, people were fairly progressive in their ideas about sharing responsibility for contraception, for example, but on other issues, SS participants were seen to hold fairly regressive views. However, again, on all indicators, the SS trainees fared better than others; they were much less likely to agree with statements, such as "you don't talk about sex, just do it" (42.7% vs. 50.7%, p < 0.01), that it is a woman's responsibility to avoid pregnancy (38.2% vs. 45.7%, p < 0.01), that men should always have the final word about decisions in the home (52.9% vs. 64.0%, p < 0.01), that an ideal husband controls his wife (71.9% vs. 75.6%, ns), and that women should give their earnings to their husbands (58.4% vs. 64.9%, p = 0.02). However, again, the views of people in SS villages were not significantly different from those of respondents in non-SS villages.
Attitudes to gender based violence and forced sex
Gender, violence and forced sex are key themes discussed in SS training and our hypothesis was that the SS trainees therefore would be adamantly against such acts. However, the PBS data showed that conventional norms are deep-seated in all groups surveyed, with a large proportion of all respondents agreeing that men could not control their sexual urges, that it is fine for a man to force his wife to have sex, and that there are times when a wife deserves to be beaten. One third of all SS respondents also believed that raped women are usually at fault. On all these issues, the SS trainees did not fare much better than other respondents in their villages although both were more enlightened than respondents in non-SS villages. Respondents in non-SS villages were more likely than those in SS villages to agree that men are unable to control sexual urges (51.2% vs. 44.8%, p < 0.01) and that it is permissible for a man to force his wife to have sex (50.3% vs. 42.0%, p < 0.01).
Behaviours: openness to new ideas
The programme implementers' expectation was that before changing major risk behaviours, people exposed to SS ideas, their friends and in turn their communities, would start to discuss sensitive issues in the home, would become more aware of HIV in their communities, be more pro-active about assisting PLHIV, and would consider HIV testing. In all these areas the SS trainees reported considerably more positive behaviours than the general population in the SS villages (Table
4). For example, they were much more likely to report recently discussing sex with their spouse (46.1% vs. 32.9%,
p < 0.01), and discussing financial issues (60.1% vs. 45.0%,
p < 0.01). They were also much more likely to say that they had been to a meeting about HIV (61.1% vs.40.6%,
p < 0.01), that they knew someone with HIV/AIDS (51.0% vs. 35.7%,
p < 0.01) and that they had personally provided help to a PLHIV (60.8% vs. 58.1%, ns). Furthermore, they were more likely to consider HIV testing (57.4% vs. 46.7%,
p < 0.01) and to actually have been tested (24.0% vs.16.9%,
p < 0.01).
Comparing the general population in SS and non-SS villages, there were no differences observed, except on the indicator relating to helping a PLHIV (58.1% vs. 45.0%, p < 0.01).
Behaviour: alcohol use and forced sex
Men were asked about their use of alcohol and perpetration of forced sex. Reported alcohol use was lower among SS male trainees than men in the general population in their villages (38.3% vs. 42.8%, ns), and this in turn was lower than in non-SS villages (48.9%, p < 0.05). We also asked men if they had ever forced a woman, including their wife, to have sex. Overall, 15% of men admitted this; 13% of young married men, 18% of older married men and 10% of unmarried men (data not shown). Despite training, forced sex (in the last 6 months) was reported significantly more in the trainee group than in the general population in their villages (9.0% vs. 5.0%, p < 0.01), but the rate in the SS villages was significantly less than in other villages (5.0% vs. 7.2%, p = 0.02).
Behaviour: risky sex
This series of indicators looked at multiple sex partners, sex with FSWs, anal sex, and use of condoms in these situations. Overall, approximately 12% of married women and 30% of married men reported ever having extra-marital sex. Among unmarried respondents, 5% of women and 15% of men reported having more than one partner in the previous six months. Overall, 15% of men reported that they had ever had sex with a sex worker; older married men were more likely to have ever done this (21%) than younger married men (15%) and unmarried men (10%).
Comparing the different groups of respondents, the results are varied. First, there was no difference between SS trainees and people in SS villages with respect to having multiple partners in the last 6 months (8.1% vs. 9.8%, ns), but the SS trainees were slightly less likely to report having had sex with an FSW in the previous 6 months (4.9% vs. 6.0%, ns). On the other hand, 5.8% of SS male trainees reported anal sex with a man in the previous 6 months, compared with only 2.2% of SS village general male population (p < 0.01). Although the number of men reporting engaging in risk behaviours was small in all three groups, the use of condoms in these encounters was overall less than half. Even some of the men trained in SS reported risky behaviour and lack of protection, although they were more likely to use condoms than men in the SS villages. Use of condoms for SS married people who had sex outside marriage was 66.6% compared with 34.3% of married people in the general population (p < 0.01). SS men were also more likely to report condom use when having sex with an FSW (59.1% vs. 43.2%, p < 0.00), or with another man (44.0% vs. 29.0%, p < 0.01).
Paradoxically, when comparing the SS villages general population with the non-SS villages general population, the former were less likely to report risk behaviours, but also less likely than men in non-SS villages to report condom use in these situations.