New STEPs in India The Snowball Effect

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• New STEPs in India The Snowball Effect
• Rosy Chhabra, Psy.D.
• Carolyn Springer, Ph.D.

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Focus on India

• 3.5 million people living with HIV in India
  (revised)
• Estimated adult prevalence .0.36
• Men 0.43, Women 0.29
• Heterosexual contact (86)
• 89 are between 15-49 years
• 30 are between 15-29 years
• 40 PLWHA are women
• Maharashtra (20 of PLWHA) is one of six Indian
  states classified as high prevalence.
• We focused our initial work with youth in schools
  of Mumbai in Maharashtra State

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Some STEPs to make the way.

• Collaborate with local CBO (DAIRRC) in Mumbai
• (DAIRRC Drug Abuse Information,
  Rehabilitation and Research Center)
• Assess needs and feasibility with focus groups
• Design the new curriculum
• Build on ideas from existing US programs (PATH,
  and Keepin It REAL)
• Tailor the new program to Indian culture
• Form Advisory Committee
• Create an IRB committee and FWA for DAIRRC
• Design a training program for 50 teen trainers

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STEP I (PILOT) Focus on HIV Prevention

• Aim was to educate Indian youth aged 13-21 about
  HIV
• Target age was 13 -15 years (8th grade).
• Train undergraduate college students (17-21
  years) using Train-the-Trainer model to teach
  children in school.
• Program effectiveness was measured by a series of
  knowledge, attitude, and behavior-related
  questionnaires.
• ANOVA was used to analyze pretest and post-test
  scores with each scale as the within-group
  measure and group (experimental vs. control) as
  the between-group measure.

STEP I was funded by World AIDS Foundation WAF
256 (01-036)
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STEP 1 Some Results! (n1846)
(N1542) Lower Score means greater agreement with
positive statements about PWHAs (Significance
level p lt.001)
(N1846) A higher score meaning greater
knowledge of HIV infection (Significance level
p lt.001)
(N1545) Lower score - more confident about
utilizing newly learned skills (Significance
level p lt.001)
(N1544) Lower score means less likely to
follow peers (Significance level plt.01)
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LESSONS FROM STEP I

• High acceptance rate and success suggests need to
  reach more schools and more students
• Increase intensity by increasing sessions from 6
  to 10
• Need longer training time / booster sessions for
  trainers
• Collect more detailed demographic/session
  information
• Assess substance use, intention and risky
  behavior along with self efficacy and social
  support
• Need to lengthen follow-up to assess the
  retention and reinforcement of the information
• Building on our success of STEP I, we put the
  ingredients together to address the synergistic
  effects of alcohol use and HIV/AIDS (STEP II)

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2nd STEP FOCUS ON ALCOHOL ABUSE and HIV/AIDS

• The target age increased to 13 -16 yrs (8th and
  9th grades)
• Plan to reach 100 schools, 60 students/school
  (n4000)
• 10 sessions over 10 weeks and a 6-month follow-up
• Wider range of program effects are measured
  knowledge, alcohol use, risk taking behavior,
  self-efficacy, communication skills, intentions
  of substance use
• Results available from first 40 schools (about
  3000 students) from Mumbai, Maharashtra
• In the experimental group The mean age was 13.9
  52 males and only about 14 had ever attended
  any kind of HIV prevention program

STEP II is funded by National Institute on
Alcohol Abuse and Alcoholism R21 AA014826
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RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS
(1)
(N2117) A higher score meaning greater knowledge
of HIV infection (Significance level p
lt.001)
(N2113) A higher score means more able to define
values regarding risky behavior (Significance
level p lt.001)
(Data analysis was conservative only students
who answered all items on any particular scale
were included)
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RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS
(2)
(N2097) Higher score means more able to deal
with peer pressure (Significance level p
lt.001)
(N2105) Lower score means less risk taking
behavior (Significance level p lt.001)
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RESULTS FROM STEP II - FIRST WAVE OF 40 SCHOOLS
(3)
(N2109 ) Higher score means a higher self
efficacy (Significance level p lt.001)
(N2060) Higher score means improved
communication skills (Significance level p
lt.001)
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OVERALL PROGRAM IMPACT

• higher level of knowledge of HIV/AIDS
• higher levels of self efficacy
• feel more able to express their own views
• higher awareness of peer behavior and influence
• less risk taking
• more confident about communicating their thoughts
  and feelings
• less likely to indicate use of alcohol in the
  next 3 months

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So what happened next?
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Snow..starting..

• Added another city (state) the Silicon Valley
  of India
• Bangalore in Karnataka (11 of cases)
• High HIV prevalence (similar to Maharashtra)
• Formed alliance with another CBO (ISBHT)
• The same process of advisory board, IRB/FWA
  setting, program and data management training
• So far we have completed the program in 20
  schools and have recruited over 2000 students

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Snow. Falling fast and plenty!

• Next Stop Himachal Pradesh
• A highly vulnerable state with low knowledge
  and low prevalence
• Small mountainous state of 6.2 million
• Primarily a rural state and has exclusive
  districts with tribal populations
• Socially disadvantaged
• 360 AIDS and 1492 HIV cases since 1992
• To date, program was completed in 24 schools
  (ngt1900)

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Snow is getting heavy.!

• Based on need, Advisory Boards insistence and
  epidemiology of CVD in India
• We added a cardiovascular health education
  program for the control group
• Assessed family history, overall health history
  (including general and mental health)
• Completed in over 44 schools (n3900)

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Still falling.

• From Bangalore schools (n832, 414 males)
• Results showed that CVD program is successful
• One health history questionnaire showed that
• Youth with positive family history of coronary
  heart disease reported significantly higher
  somatic symptoms, increased anxiety/depression
  and stress
• Positive family history of essential hypertension
  was also associated with higher somatic symptoms,
  greater anxiety/depression, higher hostility and
  higher reports of headaches.
• Positive family history of stroke increased
  self reports of allergies and stress.

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And getting heavier..

• Local CBOs trained in STEP programs got
  together in HP and have started an assessment of
  teachers and parents in the schools as well
• They have data on teachers from 18 schools
  (n600) on knowledge, attitudes/beliefs and
  confidence in teaching HIV prevention programs
  and related skills
• Writing a new grant proposal to include a teacher
  training program in future STEPS

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Starting to roll now

• The local CBO in HP, Bangalore and Mumbai also
  completed focus groups with parents of
  adolescents regarding STEP program
• 8 focus groups conducted
• We are writing a program to teach STEP as a
  complementary program for the parents as well.

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LESSONS LEARNED

• Strategies of successful technology transfer and
  implementation
• Involving community and sharing responsibility
  increases success and sustainability of programs
• Program replicates on a larger scale in affected
  urban area
• Need to expand to reach other areas of India
• Need to involve teachers in a program to increase
  sensitivity and comfort level
• Education program for parents needed to increase
  general awareness is important for sustainability
• The successful cultural adaptation of the STEP
  model shows the feasibility of adapting this
  model for use in reaching adolescents in other
  parts of the world

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New snow falling????

• Given the support of the community along with
  success and receptivity of current STEP programs
  we will consider adaptation to
• Street children
• High school dropouts
• Youth in between high school and college
• Children of the prostitutes
• College students
• Others?