Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N. Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 337:a506

Gender and Health Research Unit, Medical Research Council, Private Bag X385, Pretoria 0001, South Africa.
BMJ (online) (Impact Factor: 17.45). 02/2008; 337(7666):a506. DOI: 10.1136/bmj.a506
Source: PubMed


To assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour.
Cluster randomised controlled trial.
70 villages (clusters) in the Eastern Cape province of South Africa.
1360 men and 1416 women aged 15-26 years, who were mostly attending schools.
Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2.
Primary outcome measure: incidence of HIV. Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse.
There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)-that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months.
Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV-notably, HSV-2 and perpetration of intimate partner violence.
Clinical Trials NCT00332878.


Available from: Mzikazi Nduna
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    • "However, a more cautious analysis of the types of change that are secured by such interventions suggests that men's strides towards gender equity are at best incremental (Gibbs et al. 2014; Jewkes, Wood, and Duvvury 2010). Some interventions with men have shown an ability to reduce perpetration of violence, but the relationship between this and change in hegemonic masculinity is uncertain because the relationship between violence and hegemonic masculinity is itself contested (Jewkes et al. 2008). This observation does not mean that revolutionary change cannot ever be achieved, but it does suggest that in order to do so, interventions supporting structural and individual change need to be substantially different, and perhaps delivered over a much longer time frame than is currently common practice. "
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    ABSTRACT: The concept of hegemonic masculinity has been used in gender studies since the early-1980s to explain men’s power over women. Stressing the legitimating power of consent (rather than crude physical or political power to ensure submission), it has been used to explain men’s health behaviours and the use of violence. Gender activists and others seeking to change men’s relations with women have mobilised the concept of hegemonic masculinity in interventions, but the links between gender theory and activism have often not been explored. The translation of ‘hegemonic masculinity’ into interventions is little examined. We show how, in South Africa and Sweden, the concept has been used to inform theoretically-based gender interventions and to ensure that men are brought into broader social efforts to build gender equity. We discuss the practical translational challenges of using gender theory broadly, and hegemonic masculinity in particular, in a Swedish case study, of the intervention Machofabriken [The Macho Factory], and illustrate how the concept is brought to life in this activist work with men. The concept has considerable practical application in developing a sustainable praxis of theoretically grounded interventions that are more likely to have enduring effect, but evaluating broader societal change in hegemonic masculinity remains an enduring challenge.
    Culture Health & Sexuality 10/2015; 17(sup2):96-111. DOI:10.1080/13691058.2015.1085094 · 1.55 Impact Factor
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    • "Engendering Men: A Collaborative Review of Evidence on Men and Boys in Social Change and Gender Equality Shahrokh with Edström 'Sexual and gender-based violence' 124 intervention led to a reduction in violent and exploitative behaviours in men, including those associated with intimate partner violence, rape, and participation in transactional sex (Jewkes et al. 2008). These results have been replicated in diverse contexts, including India (Bradley et al. 2011). "
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    ABSTRACT: Three reasons to focus on men in sexual and gender-based violence (SGBV) include that: perpetrators of violence are overwhelmingly men and boys; constructions of masculinity work across individual to societal levels, driving gendered violence, and; violence is also of concern to men and boys. The evidence reviewed in this chapter reveals a series of key findings, including that a focus on attitudes alone neglects the structural violence and institutional inequalities which are shaping SGBV. Programmes explicitly addressing norms, behaviours, and relations associated with ideals of manhood can indeed be gender-transformative, but with important caveats. For example, men and boys should not be treated as a homogenous group, and programming must not reinforce binaries between men and women. Strategies need to address harmful masculinities rather than merely behaviours or attitudes. This requires engaging both men and women to challenge deeply held beliefs at the personal level, and connecting specific programmes with enabling processes of wider social change. Such enabling strategies should address the underlying drivers of violence, including socio-economic inequalities and institutionalised discrimination. Future research should include exploration of gendered power differences intersecting with other inequalities, whilst context-specific longitudinal research on transitions to adulthood should be developed alongside long-term programme evaluations. Access the chapter at
    Engendering Men: A Collaborative Review of Evidence on Men and Boys in Social Change and Gender Equality, EMERGE Evidence Review edited by Jerker Edström, Alexa Hassink, Thea Shahrokh, Erin Stern, 09/2015: chapter 7: pages 116 - 137; Promundo-US, Sonke Gender Justice and the Institute of Development Studies., ISBN: 978 1 78118 246 8
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    • "These interventions target all men and usually address the intersections between gender-based violence and HIV risks. While these have proved to be somewhat successful in changing attitudes that contribute to HIV risk and the perpetration of IPV, on the basis of men's reports of their own behaviour (Jewkes et al. 2008; Kalichman et al. 2009), there has been no systematic, independent review of programmes that have specifically targeted men who have encountered the criminal justice system and been identified as perpetrators of IPV. "
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